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  • Alex Phillipos

THE FOUNDATION

THE CORE


When dealing with lower back, middle back, and hip pain, Core exercises are commonly prescribed as a means of managing pain, minimising the risk of injury, and improving the overall function of the spine as a unit. Core strength comes up in discussions about posture, in discussions about back pain, in discussions about balance and in discussions about pain management in general. The concept of Core strength and its role in back pain emerged in the 1990s and has slowly made its way into the practical mileu, and has developed into two broad propositions:


- A weak core increases the risk of lower back injury, increases the severity of lower back pain, and slows the rehabilitation from lower back injury


- The resolution of lower back pain, and minimisation of further presentations depends on strengthening the core.


From this, we can assume that proactive investment in the "Core" muscles pays dividends down the line, in terms of minimising risk, decreasing the severity of injury, and assisting in rehabilitation. However, exercise as a whole has been shown to provide benefits to people, and there is no clear consensus on what benefits people most. This is firstly because there's a lot of research put out by a lot of people with their own varied interests and perspectives regarding what the most suitable solution is. It's also because every incidence of back pain is individual - a specific mixture factors including structural, behavioural, biological and social elements that combine together to produce a unique presentation. For this reason, people will respond differently to different exercises - some exercises will be more or less enjoyable, more or less meaningful, more or less effective.


Pain is a highly individualised experience, and so any kind of rehabilitation that is undertaken with the aim of reducing pain should be accordingly individualised. So what is the solution? Take basic principles of core strengthening and then combine them in a person-specific dose. There isn't a one-size-fits all approach to back pain because every person's spine is different, despite being made up of the same anatomy in broad strokes.


SIMPLY PUT


The "Core" refers to a harness of muscles that join the base of the ribcage with the top of the pelvis, interleaved with muscles that wrap around from the back and which insert into the midline of the body, along which the belly button can be found. There are four layers, with the abdominal muscles being closest to the skin, and with more layers of muscle going deeper. The fibers of these muscles are oriented horizontally, vertically, and diagonally, and so can contract and relax within a widely flexible range of motion. The lower back provides an example of this: you can bend forward and back, turn left and right, tilt left and right, and move the pelvis and ribcage in circles. The core is supple enough to allow ease and fluidity of movement, as well as robust enough to maintain strength and balance in any of these postures. If you've ever put together a piece of flatpack furniture, you would have had to kneel down and then reached to work on the screw, bolt or wedge part of the assembly.


The core allows our arms and head to articulate themselves on top of our ribcage, which it in turn on top of our pelvis; taking advantage of a stable base of support to interact with the world in awkward and sometimes unwieldy postures.


Some also add the muscles of the pelvis and lower back that control the legs to this definition of the core. The notion behind this is that these muscles contribute to position the center of gravity over the base of support created by the legs, and need to contract more or less tightly to ensure maintenance of that position. This changes little about the angle of attack taken in rehabilitation: Core rehabilitation is about addressing the foundation of balance, articulation of the arms and legs, and movement.


For this reason, Core training should be undertaken in three serial phases, with each phase focusing on adding functional demand to the existing system. Each diffierent functional demand is tailored to address needs in the patient's life: lifting children in the case of a daycare worker, turning quickly and moving the arms in the case of a drummer, or holding a posture in kneeling and forward trunk bend in the case of a welder or auto technician. Of course, these are only examples: everyone's life is a mixture of commitments, and so exercises need to be made to fit.


PHASE ONE


The first phase of rehabilitation comes after the initial injury has subsided, and focuses on recruitment of the core muscles: training of weak muscles and introduction of basic balance tasks. The time immediately after the resolution of pain and discomfort is the perfect moment to begin working the Core as a whole. The movements in this phase are simple muscular contractions performed in lying on the back, in which pelvic position, muscle activation, and breathing control are emphasised.


During this phase, it's important to focus on the little things. Core strength is more than clenching muscles during heavy movements or holding breath through changing postures, it's about building the endurance these muscles need to maintain a baseline level of contraction and then to increase or decrease that tension in a controlled manner depending on the task.


PHASE TWO


Phase two takes the endurance, strength, and coordination gains made in phase one and applies them to gross movements of the spine and the body. These movements are conducted in a variety of typical and atypical postures, including sitting, standing, standing on one leg, and bending. This phase focuses on using the basic skills in new contexts, in the same way that piano hand drills train familiarity with musical scales.


This phase is good for identifying shortcomings with muscle recruitment through specific movements. The movements trained are both routine ones like sitting down and standing up as well as novel ones like reaching overhead with one hand on tiptoes.


PHASE THREE


The last phase of core strength rehabilitation is to start applying resistance to the movements trained in phase two, as well as increasing the dynamism and demand of those movements. For core control, the difficulty of movements is increased by speeding up or slowing down the movement. By speeding up the movement, the core is obliged to control the limbs, direction, and force of the body on shorter notice and with less recovery time. By slowing the movement down, the body is obliged to control the posture through increasingly awkward ranges of movement, eventually progressing to static positional holds like those that might be seen in yoga.


THE POINT


The spine and the muscles that support it are powerful, flexible, and resilient. We rely on spinal strength for our entire lives, and any issue with back pain or function has the potential to impact us across many different dimensions. We need our spines, our cores, and the muscles in our limbs to perform as we need when we need them to best meet the demands of our lives, and that simply won't happen with a one-size fits all approach to treatment. The best pair of shoes is one that fits you most comfortably and which doesn't even feel like it's being worn. The best kind of treatment is the one that fits your life - works toward your strength and wellness and which doesn't force you to withdraw from any other element of your life or commitments.


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